3 New versus Established E/M codes are divided on the patient status A new patient is one who has not received any face-toface professional service from a provider of the same specialty or exact same subspecialty in the same group practice, within three years New group New Specialty If a provider is covering, the encounter is classified as it would have been by the patient s provider.

4 TIME For coding purposes, face-to-face time for office/outpatient visits or consult services is defined as only that time that the physician spends face-to-face with the patient and/or family. When greater than 50% of the face-to-face time is spent in counseling or coordination of care, time may be considered in selecting the code level for the encounter Tip: If the visit does not include any interval history ( S of SOAP note), no Physical Exam ( A ), such as a return visit to discuss test results, treatment options, compliance with treatment plan, etc. this lengthy visit would qualify for the Time component for code selection.

5 Time and Counseling Coding Issues Physicians will often need to utilize the Time factor and frequently undercode counseling types of services Diagnosis code sequencing is essential for followups; avoid denials.. After Depression or any other mental health diagnosis, etc. is determined, what physicians are actually providing is medication management. Use the V code for the subsequent encounters. V58.83 Encounter for therapeutic drug monitoring or if it is a long term current use drug, use the appropriate V58 code series Nancy Enos, FACMPE CPC CPC-I

6 Time Spent Counseling Does the note state the total time of the visit? Does the note describe the content of counseling/coordination of care? Does the note reveal that more than half of the time was spent counseling and/or coordinating care? Nancy Enos, FACMPE CPC CPC-I

7 Time and Counseling Diagnosis Coding Issues- Signs and Symptoms Anorexia (loss of appetite) Abnormal loss of weight 783.2X BMI V85.0-V85.54 Excludes: anorexia nervosa (307.1) Anorexia is an unexplained loss of appetite. Do not use this code to report anorexia nervosa, which is found in category 307 Nancy Enos, FACMPE CPC CPC-I

10 Weight Management Health and Behavior Assessment or Intervention: For dietitians, certified diabetes counselors, nurses, or behavioral health professionals for identifying the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems. These services do not represent and should not be reported on the same day as preventive medicine counseling services. Nancy Enos, FACMPE CPC CPC-I

14 Is the Service a Consultation? Was the advice or opinion of the provider requested? Was the opinion issued as per guidelines? Are these facts clearly documented in the medical record? Six R s Request (From whom?) Reason for consultation Review of previous records Render patient evaluation (H&P) Recommendation for plan of treatment Report (separate if not shared record)

15 Consultations not covered by Medicare and others following Medicare rule : Outpatient Consultations Office consults must be requested by another physician Example- Medicare will pay for surgical clearance Use if patient is considered observation status or consult is requested in ED and patient is discharged : Initial Inpatient Consultations Use if patient status is inpatient admission

16 Preventative Medicine Codes are based on New vs. Established New and Established Patient Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available. Nancy Enos Medical Coding

17 Preventative Medicine Issues The extent and focus of the service will vary based on the age of the patient If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code should also be reported

18 Preventative Medicine Issues Modifier 25 should be added to the Office/ Outpatient code to indicate that a significant, separately identifiable Evaluation and Management service was provided by the same physician on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported. An insignificant or trivial problem or abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-oriented E/M service, should not be reported.

19 Preventative or Sick? A 72 year old established patient presented for a well check-up. The patient s daughter claimed the patient had been walking with a limp and complaining of lower leg pain for the past 3 days after falling from the bed. The provider focused on further (extensive) evaluation of these symptoms and indicated a plan of x-ray and possible referral to orthopedics. The preventative exam was completed. The bill would look something like this:

21 Nurse Visits According to the CPT manual, a is an office or other outpatient visit "that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services." Unlike the rest of the office visit codes, does not have any documentation requirements for the history, physical exam or complexity of medical decision making. The nature of the presenting problem need be only "minimal," such as monthly B-12 injections, suture removal, dressing changes, allergy injections with observation by a nurse, and peak flow meter instruction Do not use for shot visits the administration codes include the work of Remember, if you bill a you must collect a copay

26 Advanced Beneficiary Notice (ABN) Requirements A physician should obtain an Advanced Beneficiary Notice (ABN) when services provided fall outside of Medicare coverage requirements. The ABN can be found on the CMS website at: g.pdf Physicians, practitioners and hospitals will be liable for Screening services unless they issue an appropriate Advanced Beneficiary Notice

27 Medicare Preventative Services Under PPACA (Patient Protection and Affordable Care Act, or Healthcare Reform) coverage for preventative services has been expanded. Medicare continues to define the conditions of coverage of preventative services Not all commercial plans will follow the Medicare Guidelines

30 First Annual Wellness Visit (AWV) Once in a lifetime exam including Personalized Prevention Plan Services (PPPS) Person Covered- One who is no longer within 12 months after the effective date of first Medicare Part B Coverage One who has not received either an initial preventative physical exam or an AWV within the past 12 months.

31 AWV Includes Establish or update the individual s medical and family history. List the individual s current medical providers and suppliers and all prescribed medications. Record measurements of height, weight, body mass index, blood pressure and other routine measurements. Detect any cognitive impairment. Establish or update a screening schedule for the next 5 to 10 years including screenings appropriate for the general population, and any additional screenings that may be appropriate because of the individual patient s risk factors. Furnish personalized health advice and appropriate referrals to health education or preventive services.

32 Annual Wellness Visit (AWV) Review of individual s potential for depression Including current or past experiences Review functional ability and level of safety based on direct observation or screening questions/questionnaire

33 Annual Wellness Visit (AWV) Establish a written screening schedule for the individual, such as a checklist for the next 5-10 years, as appropriate Patient s health status Screening History Age appropriate preventive services

35 Annual Wellness Visit (AWV) Any other element(s) determined appropriate by the Secretary of Health and Human Services through the National Coverage Determination (NCD) process Not subject to incident-to Who may perform? Doctor of medicine, Doctor of osteopathy Nurse practitioner, Physician assistant, Clinical nurse specialist Health professional, which includes: Health educator, Registered dietitian Nutrition professional, Team of such medical professionals who are working under the direct supervision of a physician

36 Subsequent Wellness Visit (SWV) Performed 11 months after AWV & includes Update to medical/family history Measurements of weight (or waist circumference), blood pressure and routine measurements as deemed appropriate Update to list of current medical providers/suppliers Detection of any cognitive impairment Update to written screening schedule Update to list of risk factors Furnish appropriate health advice and referral as appropriate

39 Is a Shared Medical Appointment Billable with E/M codes? AAFP asked CMS if an E/M code such as might br appropriate to bill for a f-t-f visit in the course of a SMA, the context of which is educational

40 CMS Guidelines to AAFP The response from CMS was, "...under existing CPT codes and Medicare rules, a physician could furnish a medically necessary face-to-face E/M visit (CPT code or similar code depending on level of complexity) to a patient that is observed by other patients. From a payment perspective, there is no prohibition on group members observing while a physician provides a service to another beneficiary." The letter went on to state that any activities of the group (including group counseling activities) should not impact the level of code reported for the individual patient.

42 Other Code Options If your group visits include the services of nutritionists or a behavioral health specialist, contact payers to determine if that portion of the group visit can be directly billed by the non-physician provider. This typically would include codes for medical nutrition therapy (97804) or health and behavior intervention (96153). Other codes that may be applicable are the codes for education and training for patient self-management involving a standardized curriculum ( ). Neither these codes nor medical nutrition or behavioral health therapy are billed by physicians. Physicians must use evaluation and management codes to report these services. Code describes physician educational services in a group. Again, it is necessary to contact the payer to verify that coverage of this service is a payable benefit.

43 Guidance from the CDC on Health Risk Assessment At the request of the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC) is providing initial guidance on the development of a health risk assessment tool. kassessmentscdcfinal.pdf

44 Insurance Coverage Issues Insurance plans vary on the range of services covered by a patient s policy High deductibles, copays, co-insurance should be verified before providing a service Medical Necessity is key Preventive services are often covered but research your contacted payers for their reimbursement policies

45 CPT codes, descriptions and material only are copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

46 About the Speaker Nancy M Enos, FACMPE, CPMA CPC-I, CEMC is an independent consultant with the MGMA Health Care Consulting Group. Mrs. Enos has 35 years of experience in the practice management field. Nancy was a practice manager for 18 years before she joined LighthouseMD in 1995 as the Director of Physician Services and Compliance Officer. In July 2008 Nancy established an independent consulting practice, Nancy Enos Medical Coding ( As an PMCC and ICD-10 Instructor by the American Academy of Professional Coders, Nancy provides coding certification courses, outsourced coding services, chart auditing, coding training and consultative services and seminars in CPT and ICD-9and ICD-10 Coding, Evaluation and Management coding and documentation, and Compliance Planning. Nancy frequently speaks on coding, compliance and reimbursement issues to audiences including National, State and Sectional MGMA conferences, and at hospitals in the provider community specializing in primary care and surgical specialties. Nancy is a Fellow of the American College of Medical Practice Executives. She serves s as a College Forum Representative for the American College of Medical Practice Executives. She is on the board of Eastern Section MGMA and serves as Past President.

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